In January, at a pediatrician appointment for my then six-month-old daughter, I was handed an iPad-like device and asked to respond on a scale of 1 to 10 to prompts such as: 'In the past seven days, I have been able to laugh and see the funny side of things,' and 'I have been anxious or worried for no good reason.'
The questionnaire is part of the Edinburgh Postnatal Depression Scale (EPDS), which is used to detect postpartum depression among mothers globally. A score of 10 or higher, or a positive answer to question #10 — 'The thought of harming myself has occurred to me' — is suggestive of postpartum depression, while women who score above 13 are likely suffering from a depressive illness of varying severity.
The American College of Obstetricians and Gynecologists (ACOG) recommends screening all women at least once for depression and anxiety during the perinatal period, which is usually defined as the later weeks of pregnancy through the weeks following birth. Additionally, the American Academy of Pediatrics (AAP) encourages pediatricians to screen new moms at the one-, two-, four-, and six-month mark. But just because it's encouraged, doesn't mean it's done. I'm actually at a forward-thinking pediatrician's office in that they do these screenings.
It feels impersonal, but screenings are important. They can catch mental health conditions early. They can save lives.
Amid reports that 15 to 20 percent of women experience a perinatal mood disorder (PMAD) during pregnancy or up to a year postpartum, including depression, anxiety, or OCD, what often goes unreported is that suicide is a leading cause of death in the postpartum period.
A recent study in The American Journal of Obstetrics and Gynecology found that deaths by suicide, in combination with accidental drug-related deaths, accounted for almost 20 percent of postpartum deaths. That study — which looked at about one million women who gave birth in California from 2010 to 2012 — found that of 300 women who died during a one-year follow-up period, suicide was the seventh leading cause of death, accounting for 15 deaths. (The leading cause of death was obstetric-related problems.)
Data suggests the rate of maternal mortality by suicide varies from 5.3 to 6.5 percent; about the rate of death by suicide for women. But the number of deaths by suicide among new mothers is still higher than expected, explains Claire Margerison, Ph.D., a perinatal epidemiologist at Michigan State University who co-authored the The American Journal of Obstetrics and Gynecology study.
Moms are also often left out of the suicide conversation. "Suicide is a big problem in the U.S. Rates have been increasing but mothers, especially new mothers, are not focused on when we talk about suicide prevention," says Sidra Goldman-Mellor, Ph.D., M.P.H., an assistant professor of public health at the University of California, Merced.
Further: A recent review of research published in The American Journal of Obstetrics & Gynecology calls these deaths an "unrecognized and preventable outcome."
So why aren't we talking about it?
Why Maternal Suicide Remains a Silent Issue
The reasons that maternal death by suicide remains underreported are many, starting with issues involving how these deaths are reported in the first place.
First, while today, death certificates in all 50 states include a pregnancy status 'checkbox', that addition is fairly new. It wasn't until 2003 that the Centers for Disease Control and Prevention (CDC) urged states to include the checkbox — and, according to the new data from the CDC released last week about maternal mortality in this country, it wasn't until 2017 when the last state adopted this checkbox item.
But there is also an issue with how 'maternal mortality' is defined in the first place. While the Centers for Disease Control and Prevention (CDC) says that a 'pregnancy-related' death is a death of a woman while pregnant or within one year of the end of pregnancy, 'maternal mortality' is defined by the World Health Organization (WHO) as the death of a woman while pregnant or within 42 days of termination of pregnancy. Those new statistics about maternal mortality, released by the CDC in late January, include the 42-day definition.
But many argue this definition of maternal mortality falls short. It doesn't include deaths deemed 'accidental' or 'incidental' meaning suicides are left out of the statistics, explains Panagiota Kitsantas, Ph.D., a professor of biostatistics and epidemiology at George Mason University. "Currently, the process of identifying and correctly classifying maternal deaths due to self-harm is minimal to non-existent."
She adds: "The lack of research studies in this field and funding resources, as well as the fact that suicide has been excluded from the definition of maternal mortality have turned maternal deaths by suicide into an unrecognized public health issue. This is sad given that it is a preventable outcome."
It's also challenging to differentiate maternal deaths due to suicide from other causes of death, such as drug overdose-related ones, Kitsantas notes. All of these reporting issues mean the number of maternal deaths by suicide could have been underestimated for years, she explains.
Then there's the issue of the mere classification of terms such as postpartum depression (PPD). While you've likely heard 'PPD' before — and doctors have used it since the 1980s — postpartum depression was not even formally added to the Diagnostic and Statistical Manual of Mental Disorders (DSM), the "bible" of psychiatric disorders, until 1994.
Even today, PPD is referred to in the DSM as Major Depressive Disorder "with peripartum onset," which means depressive episodes have occurred during pregnancy or in the four weeks postpartum. Researchers are currently working to get postpartum psychosis, a rare illness with symptoms such as delusions, hallucinations, and rapid mood swings, into the DSM.
It's a step forward but many experts and organizations, including Postpartum Support International (PSI), a non-profit dedicated to perinatal mood and anxiety disorders, feel as though the period following delivery should have been extended past a month "to recognize that real suffering often occurs during the first year."
After all, some research finds that the peak in maternal deaths by suicide happens between 9 and 12 months postpartum — far past that month marker point.
Pregnancy, New Motherhood, and the Stigma That Lingers
Today, we know that monumental physical, hormonal, and brain changes take place during pregnancy and the postpartum period.
During the 40-some weeks of pregnancy, your hormone levels increase (levels of the hormone progesterone, often called 'the pregnancy hormone,' alone increase between six- and eight-fold), then, in 24 hours after delivery (or after a miscarriage or abortion) they are gone. "That's a real jolt to the central nervous system," explains Margaret G. Spinelli, M.D., a clinical professor of psychiatry at Columbia University.
The drop in hormones can impact receptors, neurotransmitters, and chemical details in the brain, she explains. While the 'baby blues' — a feeling of sadness or moodiness after giving birth — happen to about 80 percent of women, feeling depressed or even having mixed feelings during pregnancy, having a history of depression or bipolar disorder, or a lack of social support can all increase your risk of postpartum depression.
In 2020, this is still relatively new information. Rewind to the early 1980s and you might find physicians in this country telling women that their mood was "protected" during pregnancy and postpartum, Dr. Spinelli explains. You'd find research papers making claims such as "the incidence of mental illness is substantially lower in pregnancy" and "without exception, the changes are in the direction of improved physical and psychological health after delivery."
They're incorrect statements, of course, says Dr. Spinelli, but at the time they created a workforce of doctors that didn't know much — if anything at all — about mental health concerns in the perinatal period. In fact, Dr. Spinelli recalls having to travel to London in 1987 after med school to learn about perinatal mental illness because "there was no such thing as 'perinatal psychiatry' in the United States," she says.
Today, stigma around mental health — specifically mental health during pregnancy — still exists.
"Maternal death by suicide clashes or counters the societal idealism of a pregnancy and the overall picture of a happy mother and her infant as being positive and rewarding experiences," explains Kitsantas.
Amplified by the belief that disclosing mental health problems may lead to possible parental rights termination, it may even deter women from seeking mental health treatment, she says. It also could lead new moms to lie on mental health screenings like the one I took. With little context, holding an iPad sitting in the pediatrician's office with your newborn baby responding to statements like, things have been getting on top of me, you might not always be inclined to tell the truth.
In fact, a 2018 study found that stigma was the biggest barrier for women in disclosing postpartum mood symptoms, and it can have devastating effects.
"This 'clash' between what society recognizes as the norm (a happy expectant mother) and the despair, depression, and psychotic symptoms a pregnant women or a new mother may experience may drive them toward suicide ideation and attempt," says Kitsantas.
What You Can Do to Help
Suicide is a complex issue. And when it comes to addressing the issue of maternal suicide, there are broader societal, cultural, and infrastructural changes that must take place.
For one, increasing awareness of the emotional changes that go on during pregnancy, something groups such as PSI work to do, is key in changing the conversation about how a pregnancy or postpartum period might look or feel.
"Changes in health insurance policies and public funding for access to mental health services and treatment can greatly help those pregnant and postpartum women who are in need of these services," adds Kitsantas. "Finally, standardizing the definition of maternal mortality to include maternal deaths resulting from self-harming behaviors is an extremely important step in identifying and measuring this major preventable public health issue."
On an individual level? There are almost always multiple reasons why someone might take their life, but experts say risk factors for maternal self-harm-related deaths include a depression diagnosis, substance use disorder, the presence of another psychiatric condition, a history of self-harm, current psychiatric care treatment, and recent illness onset, among other things.
Talking about wanting to die or to kill oneself
Talking about feeling hopeless or having no reason to live
Talking about feeling trapped or in unbearable pain
Talking about being a burden to others
Acting anxious or agitated; behaving recklessly
More research is needed to fully understand other factors, including personal and family history of mental illness, and how they influence the risk of suicide ideation and attempt in pregnant or postpartum women, Kitsantas says.
Finding a therapist or support group, building a support network, and learning to recognize warning signs, as well as having a plan to cope with them if they arise, can all help you help yourself in moments of need.
If you're concerned about someone you love, speak up. Ask them: Have you had thoughts of suicide? Many people worry that asking this could actually increase the risk that someone dies by suicide but it does not increase risk, says Dr. Spinelli. "If anything, it's a relief."
If a person you love says that they are considering suicide, take them seriously, stay with them in a safe environment, and call the National Suicide Prevention Hotline (1-800-273-8255).
If you're in crisis, call the hotline or contact the Crisis Text Line by texting TALK to 741741, call 911, or go to your nearest hospital.
Maternal death by suicide is preventable.